Compatible Clinical Picture Research Articles

Manifestation of ocular tuberculosis in a north Indian tertiary care centre: Case series

Ocular tuberculosis acts as a challenge throughout the world, and its pathophysiology, diagnosis, and treatment are a topic for debate. The present case series represents retrospective study focusing on the variable clinical presentations, the diagnostic and therapeutic characteristics of ocular tuberculosis. We report 12 patients of ocular tuberculosis with variable presentations. : Retrospective analysis of records of patients diagnosed with ocular tuberculosis from August 2022 till March 2023 was done. Diagnosis of ocular tuberculosis was based on detailed ocular and systemic examination including best corrected visual acuity (BCVA), Slit lamp examination, fundus examination, OCT. The patients presenting with features suggestive of ocular tuberculosis were further investigated with complete blood count (CBC), erythrocyte sedimentation rate (ESR), Monteaux test, Chest X-ray, Cartridge Based Nuclear Amplification Test (CBNAAT) and rheumatological work up. Out of 12 of ocular tuberculosis patients, 4 were diagnosed with active retinal vasculitis, 3with choroiditis, 3 had panuveitis, and remaining 2 patients had unilateral nodular episcleritis. The diagnosis was based on compatible clinical picture, highly positive Tuberculin skin test and dramatic response to anti-tuberculous drugs. All 12 cases were strongly Mantaux test positive (2 developed injection site ulceration). All cases were started on ATT immediately with pulmonologist consultation and showed clinical improvement after 1 month. Ocular tuberculosis can have myriad presentations. Positive Mantaux test plays an important role in supporting diagnosis of ocular tuberculosis.

Tuberculosis of the eye, case series study.

Tuberculosis of the eye represents a challenge throughout the world, and there is a continuous debate about its pathophysiology, diagnosis, and treatment. The present research represents an interventional prospective study focusing on the variable clinical presentations, and the diagnostic and therapeutic characteristics of ocular tuberculosis. Fifteen eyes from nine cases were diagnosed with ocular tuberculosis, treated, and followed up between 2010 and 2020. The diagnosis was based on (1) a compatible clinical picture, (2) highly positive Tuberculin skin test or a positive IGRA test (Interferon-Gamma Release Assays), (3) a dramatic response to anti-tuberculous drugs without systemic steroid. Mean age was 41.22±13.64 years; eight cases were females 89.8%, one male 11.1%. Only one case had preexisting pulmonary tuberculosis. Bilateral ocular involvement occurred in two thirds of cases (66.7%). The most common clinical presentation was intermediate uveitis (33.3%), followed by multifocal choroiditis (20%). All cases were cured without relapse for the 2–10 years of follow-up, after taking oral anti-tuberculous drugs for 6–12 months. No systemic steroids were given, only topical steroid drops, as indicated. In conclusion, ocular tuberculosis is a mysterious condition with a wide-range of clinical presentations and should be considered in the differential diagnoses of any type of intraocular inflammation, or any unexplained reduction in vision. Oral anti-tuberculous drugs with or without topical steroids are sufficient to improve vision, produce, cure, and prevent relapse.

Actinomycose pulmonaire à Actinomycesodontolyticus chez un enfant de 2 ans

Pulmonary actinomycosis due to Actinomyces Odontolyticus is a rare and seldom reported pathology in pediatrics. The unspecific radio-clinical symptomatology and the slow growth of the germ make the diagnosis difficult. A 2-year-old boy is admitted to the emergency room for acute respiratory distress in a context of febrile bronchitis that had been evolving for 10days. Quickly, the patient's state deteriorate, invasive ventilation was required. Bronchial fibroscopy was performed immediately and enabled extraction of large mucous filaments, leading to significant improvement. Mechanical ventilation was stopped after 72hours. Five days later, blood culture tested positive for Actinomyces Odontolyticus. In the absence of any other cause and given a compatible clinical picture, the child was treated with long-term antibiotherapy for a total duration of 6months, which was stopped following reassuringly normal endoscopic and radiological control. This is the second pediatric case of pulmonary actinomycosis due to A. Odontolyticus reported in the literature. The clinical symptoms and imaging are not specific. The presence of sulphide granules on pathological examination or in germ culture at a sterile site confirms the diagnosis. Prolonged antibiotic therapy is still recommended to avoid pulmonary sequels.

LACTOBACILLUS ENDOCARDITIS, A SINISTER CONSEQUENCE OF AN INNOCUOUS BACTERIUM

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lactobacillus species are gram positive rods that are part of the normal flora in gastrointestinal, oropharyngeal and genital tracts. Rarely they are implicated as causative agents of endocarditis in patients who are immunocompromised, undergo dental procedures, use probiotics or have a valvulopathy or prosthetic device. We describe the case of lactobacillus jensenii causing aortic valve endocarditis in an immunocompetent patient with a bicuspid aortic valve. It is important to recognize lactobacillus species as an emerging cause of endocarditis. Treatment involves a synergistic combination of penicillin and gentamicin. CASE PRESENTATION: 55 years old female with past medical history of bicuspid aortic valve presented to the emergency department with chief complaint of fever of 3 weeks' duration. COVID-19 testing was negative. Her medical history was significant for bicuspid aortic valve with aortic regurgitation and hyperlipidemia. Vitals signs were significant for a fever of 103 F. Physical exam was remarkable for a diastolic murmur heard best in the left third intercoastal space. Labs showed a normal blood count, and electrolytes. Patient's blood and urine cultures were obtained, and they were sent home with an oral antibiotic only to be called two days later for a positive blood culture. Blood cultures initially grew gram positive bacilli and patient was started on vancomycin and piperacillin-tazobactam pending final cultures. Due to her history of bicuspid aortic valve, endocarditis was suspected, and patient underwent transesophageal echocardiogram (TEE) which showed a 10-millimeter vegetation attached to the non-coronary cusp of aortic valve. Blood cultures came back positive for lactobacillus jensenii. Patient satisfied the Duke's criteria for endocarditis and was switched to penicillin and gentamicin. Further history did not elicit further risk factors of lactobacillus endocarditis including probiotic use, recent dental work, and immunodeficiency. Patient completed six weeks of antibiotics and had negative final blood cultures. DISCUSSION: This case highlights the importance of lactobacillus species to be a causative factor of endocarditis in patients with a predisposing risk factor. These risk factors include, in order of decreasing frequency, valvulopathy, dental procedures, probiotic use and immunosuppression. It is important to consider lactobacilli as a causative agent of infection if they are isolated on routine blood cultures in predisposed patients with a compatible clinical picture. TEE should be done if endocarditis is suspected. Lactobacilli are highly sensitive to penicillin G and synthetic penicillins. However, they are usually resistant to vancomycin. This is important as vancomycin is an integral regimen of most initial sepsis regimens. CONCLUSIONS: . REFERENCE #1: Campagne, J., J. F. Guichard, M. C. Moulhade, H. Kawski, and F. Maurier. "Lactobacillus endocarditis: a case report in France and literature review." IDCases 21 (2020): e00811. REFERENCE #2: Prendergast, B. D. "Diagnostic criteria and problems in infective endocarditis." Heart 90, no. 6 (2004): 611-613. DISCLOSURES: No relevant relationships by Muhammad Hasib Khalil, source=Web Response

Acne keloidalis nuchae and thyroid diseases: a population-based cohort study.

The association between acne keloidalis nuchae (AKN) and thyroid diseases is yet to be investigated. To evaluate the risk of developing hypothyroidism and hyperthyroidism among patients with AKN and to characterize the patients who have AKN and thyroid comorbidities. A population-based cohort study was conducted comparing AKN patients (n=2,677) with age-, gender-, and ethnicity-matched control subjects (n=13,190) with regard to incident cases of hypothyroidism and hyperthyroidism. Adjusted hazard ratios (HRs) were estimated by Cox regression analysis. The incidence rates of hypothyroidism among patients with AKN and controls were estimated at 2.15 (95% CI, 1.49-2.99) and 0.82 (95% CI, 0.66-1.00) cases/1000 person-years, respectively. The crude risk of developing incident hypothyroidism was 1.85-fold greater in patients with AKN (HR, 1.85; 95% CI, 1.24-2.78; P=0.003). The elevated risk persisted following the adjustment for putative confounders (adjusted HR, 1.72; 95% CI, 1.03-2.89; P=0.040). The risk of hyperthyroidism was comparable in patients with AKN and controls both in the crude (HR, 1.55; 95% CI, 0.57-4.22) and adjusted (adjusted HR, 1.92; 95% CI, 0.59-6.21) analyses. Patients with coexistent AKN and thyroid diseases were significantly older at the onset of AKN, had more prominent female preponderance, and had a higher burden of comorbidity. Patients with AKN are at an increased risk of hypothyroidism. Screening for hypothyroidism should be considered in AKN patients with a compatible clinical picture.

Candidemia: Predisposing Factors, Antifungal Susceptibility, Clinical Outcome and Connotations for Management

Objective: We conducted this study to investigate the epidemiology of candidemia in our setting and to quantify the risk factors associated with disease, overall outcome, and mortality associated with candidemia. Methods: In this prospective observational study, we conducted lab-based surveillance with clinical correlation of all cases of candidemia within our ICUs during the period (2016–2018). Clinical assessment was done on day 5 and day 30, and comorbidities, clinical features, and outcome were observed within 30 days after the diagnosis. The diagnosis was made on the basis of positive blood culture for Candida spp and a compatible clinical picture. The demographic characteristics, sequential organ failure assessment (SOFA) scores, comorbidities, use of invasive devices, antibiotics administered were observed, and antifungal susceptibility testing was performed according to CLSI guidelines. Type and duration of antifungal administered and outcomes were noted. Results: In total, 48 episodes of candidemia, with 29 (60%) males and 19 (40%) females, were identified during the study period. C. albicans was the most common specie responsible for candidemia, causing 17 of the cases (~35%), whereas rest of the cases were caused by non–albicans spp, which included C. auris, accounting for 9 (19%) C. parapsilosis and C. tropicalis 7 (15%) each, C. glabrata and C. famata 2 (6%), and C. krusei was isolated in only 2 cases (4%). Among modifiable risk factors, CVC insertion and antibiotic exposure were the leading factors, seen in 100% of patient. Candida colonization was observed in 26 patients (28%), of whom 2 (4%) had multifocal Candida colonization. Among evaluable patients, 17 (35%) died within 30 days of the onset of candidemia. C. tropicalis was associated with the highest mortality rate, 27% (n = 4) in this cohort. Regarding the crude mortality in the different units, patients in medical ICU had the highest mortality rate (54%). In vitro activity of 3 systemically active antifungal agents was tested against 48 isolates of Candida spp. Based on CLSI break points, the susceptibility to voriconazole was 98%; only 1 isolate was resistant to voriconazole. Among candidemia-positive cases, 28 patients (58%) had taken the antifungals for >14 days, whereas 18 (37.5%) were treated for <14 days and 2 (4%) died before the initiation of therapy. Conclusions: In our study, C. albicans was the most common specie responsible for candidemia, but non–albicans spp are also emerging, with higher in vitro resistance to antifungals.Funding: NoneDisclosures: None

ILEOCOLIC INTUSSUSCEPTION: A RARE CASE REPORT OF MULTI-SYSTEMIC SARCOIDOSIS

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Sarcoidosis is a chronic inflammatory granulomatous disease of unclear etiology with multi-organ involvement, commonly affecting pulmonary and cutaneous systems. Gastrointestinal (GI) tract is rarely involved, if so, usually in stomach. This case highlights a rare involvement of small intestine in multi-systemic sarcoidosis management. CASE PRESENTATION: 56-year old male with history of pulmonary and cutaneous sarcoidosis and nephrolithiasis, without major surgical history presented to ED for acute generalized non-radiating left lower abdominal pain followed by persistent non-bilious, non-bloody vomiting and non-bloody diarrhea, within 24 hours. Patient had preceding subjective fever, chills, rigors, and diaphoresis. Medications included prednisone, levothyroxine, citalopram, omeprazole and rosuvastatin. Vital signs were within normal limits. Physical exam showed distended abdomen, bilateral lower quadrant tenderness and rebound tenderness at the supra-umbilical region with hypoactive bowel sounds. Laboratory studies showed a leukocytosis with left shift, elevated levels of creatinine, calcium, and alkaline phosphatase. He underwent emergent ileocectomy after CT abdomen and pelvis that demonstrated ileocolic intussusception with small bowel obstruction. Surgical biopsy revealed inflammatory non-caseating granuloma. GMS stains and AFB were negative. Diagnosis of GI Sarcoidosis was made. DISCUSSION: Although the clinical manifestation of GI sarcoidosis is rare, one can aid early diagnosis by thorough clinical picture, histopathological evidence of non-caseating granuloma and exclusion of other causes of similar clinical presentations. CONCLUSIONS: GI Sarcoidosis requires a high index of suspicion. Only 0.1-0.9 % of Sarcoidosis patients have GI manifestations. Extrapulmonary and multiple system sarcoidosis should be considered in patients with compatible clinical picture and histopathological evidence of non-caseating granuloma in any accessible biopsy site. Reference #1: Ghrenassia E, Mekinian A, Chapelon-Albric C, et al. Digestive-tract sarcoidosis: French nationwide case-control study of 25 cases. Medicine (Baltimore). 2016;95(29):e4279. doi:10.1097/MD.0000000000004279 Reference #2: Stemboroski L, Gaye B, Makary R, Monteiro C, Eid E. Isolated Gastrointestinal Sarcoidosis Involving Multiple Gastrointestinal Sites Presenting as Chronic Diarrhea. ACG Case Rep J. 2016;3(4):e198. Published 2016 Dec 21. doi:10.14309/crj.2016.171 DISCLOSURES: No relevant relationships by Nancy Bethuel, source=Web Response No relevant relationships by Yuri Choi, source=Web Response No relevant relationships by Nazir Lone, source=Web Response

Serologic characterization of anti-p200 pemphigoid: Epitope spreading as a common phenomenon

To the Editor: Anti-p200 pemphigoid is an autoimmune blistering disease characterized by circulating autoantibodies binding to the dermal side of human salt-split skin (SSS) by indirect immunofluorescence (IIF) microscopy and reactivity against a 200-kDa protein in the extract of human dermis by immunoblotting (IB).1 Laminin γ1 has been identified as a major target antigen and can be detected in about 90% of sera.2 This retrospective single-center study included all 245 anti-p200 pemphigoid sera analyzed between 2008 and 2017 in our routine autoimmune laboratory with a compatible clinical picture and reactivity with the p200 protein.

Coxiella burnetti Infection in Children

The epidemiology, clinical manifestations, and management of Coxiella burnetti infection in children have not been summarized and updated since 2002. Aerosolization from the birth process of infected mammals accounts for almost all cases. Diagnosis requires a compatible clinical picture and serology that meets the criteria for acute or for persistent focal (chronic) infection. Acute disease is rarely diagnosed in children but it is not clear whether this is because infection is rare, infection is usually asymptomatic, or the diagnosis is usually missed. Fever is the main manifestation of acute disease; there are remarkably few case reports of pneumonia in children and almost none of hepatitis. There are no well-documented cases of breast milk transmission. Cases of persistent focal infection manifesting as endocarditis (N = 18) and osteomyelitis (N = 28) are summarized. The majority of cases of the latter progress to chronic recurrent multifocal osteomyelitis (CRMO). There are no published recommendations for management of acute or persistent focal infection in children. The possibility of C. burnetti infection should be considered for all children with culture-negative endocarditis or with CRMO. Exposure at any time to parturient mammals increases the risk of infection, but because the bacteria travels long distances on the wind, the absence of such a history should not preclude requesting serology. The selection and duration of antibiotics for persistent focal infection should be extrapolated from adult recommendations.

Usefulness of serology in diagnosis of different clinical presentations of ocular toxoplasmosis

Background: Large proportions of acquired cases of ocular toxoplasmosis are reported with atypical presentations. The objectives of the study were to find out whether any correlation existed between serological findings of typical and atypical presentations of ocular toxoplasmosis as compared to cases presenting with non-toxoplasmic uveitis and to find out the proportion of various atypical presentations of ocular toxoplasmosis.Methods: It was a prospective observational study.The study subjects of ocular toxoplasmosis were tested for immunoglobulin M (IgM) and immunoglobulin G (IgG) toxoplasma antibody levels in serum by ELISA (enzyme-linked immunosorbent assay) technique. The proportion of atypical presentation among total toxoplasma cases and distribution of atypical cases were calculated. Fisher’s exact test, one-way analysis of variance and Kruskal-wallis test were used as applicable.Results: Among the cases (n=35) thirteen patients had typical presentation of a retinochoroidal focus with an adjacent scar and 22 patients had atypical features. Control group consisted of 24 patients. Various types of presentations in atypical cases were retinitis patch without an adjacent scar (31.8%), intermediate uveitis (27.3%), papillitis (22.7%) retinal vasculitis and dense vitritis (9.09% each). Mean IgG levels in typical cases (85.3±82.9 IU/ml) and atypical cases (47.5±66.2) were significantly higher than control group (6.6±3.4, p<0.001).Conclusions: Serology is a useful tool in the diagnosis of ocular toxoplasmosis with a compatible clinical picture as serum IgG levels are significantly elevated in both typical and atypical presentations of ocular toxoplasmosis as compared to cases presenting with non-toxoplasmic uveitis.

Ocular syphilis in an immunocompetent man.

A healthy 47-year-old immunocompetent man from Northern Canada presented for ophthalmologic assessment after experiencing one month of right-sided photopsias, floaters, and a right lower nasal quadrant visual field defect. Optic disc swelling, vitritis, chorioretinitis, peripheral retinal infiltrates and hemorrhages were noted in the right eye. A broad right inferior arcuate and nasal visual field defect were also present. Fluorescein angiography of the right retina showed dilated disc vessels and staining of the optic disc.Treponemal antibody testing, using chemiluminescent microparticle immunoassay, was highly positive; this was followed by a Venereal Disease Research Laboratory (VDRL) test with a titre of 1:32 and confirmed by Treponema pallidum particle agglutination (TP-PA) test. Testing did not demonstrate any co-infections.Cerebrospinal fluid (CSF) analysis revealed strong reactivity (4+) to the Treponemal antibody by immunofluorescence antibody absorbed (FTA-ABS) test and non-reactivity by CSF VDRL test. Syphilis PCR of CSF was negative. A diagnosis of neurosyphilis was made. He was treated with ceftriaxone 2 grams IV q24h for 14 days. The vitritis gradually improved.Familiarity with syphilis diagnostics is becoming increasingly important, especially given its recent resurgence amongst several at risk groups. This patient’s case highlights that non-reactive CSF VDRL is not a reliable test in the context of positive serum results and a compatible clinical picture. CSF Treponemal tests such as TP-PA and FTA-ABS offer higher sensitivity than non-treponemal tests such as VDRL in the context of CNS involvement and ocular syphilis.

MEDIASTINAL TB PRESENTING AS RIGHT MIDDLE LOBE SYNDROME WITH PIGMENTED AIRWAYS ON BRONCHOSCOPY

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Mediastinal tuberculous lymphadenitis (MTLD) is an uncommon manifestation of tuberculosis (TB). We describe a case of MTLD in an adult with a recent history of pleurisy, presenting as right middle lobe syndrome, found to have black mucosal discoloration on bronchoscopy. CASE PRESENTATION: A 60-year-old Afghan female was evaluated for chronic cough. She previously immigrated from Pakistan, at which time she was evaluated for a pleural effusion and positive tuberculin skin test (20mm). Thoracentesis revealed a lymphocytic effusion, normal glucose, low ADA, and negative AFB. She did not complete an isoniazid course, yet her effusion resolved. Two years later, she presented with 2 months of cough, rare hemoptysis, fatigue, night sweats, and dyspnea. She was frail, nontoxic, with a dry cough and coarse right parasternal breath sounds. CT chest showed calcified hilar and mediastinal lymphadenopathy with right middle lobe atelectasis [Figure 1]. Bronchoscopy revealed black mucosal plaques [Figure 2], with a nodular bronchus intermedius lesion obstructing the middle lobe [Figure 3]. Biopsy showed plasma cells, eosinophils, and basement membrane thickening; no malignancy or granulomas. Bronchoalveolar lavage (BAL) and stains for acid-fast and fungal organisms were all negative. She was started on isoniazid and rifampin, with marked improvement at 1 month; CT chest at 2 months showed increased right middle lobe aeration [Figure 4]. She was diagnosed with culture-negative TB, treated with 9-months of therapy. DISCUSSION: Pleurisy is common in primary TB, and often resolves spontaneously1, but one-third have reactivation2. Lymphadenopathy is characteristic of primary disease, but isolated MTLD is unusual in post-primary TB3. Yield of sputum, BAL, and transbronchial biopsy is low in MTLD due to microorganism burden4. EBUS can aid in diagnosis in 42-85%, and mediastinoscopy is an option if benefit outweighs risk5. In a patient with compatible clinical picture, culture-negative TB may be diagnosed after demonstrating response to therapy6. Black airway pigmentation is nonspecific, seen in malignancy, anthracosis, soot, and infections such as Aspergillus and Mycobacterium tuberculosis7. Mechanism is not fully understood, but may reflect rupture of lymph nodes with pigment-laden macrophages into bronchial mucosa7. Despite treatment, it is often irreversible. CONCLUSIONS: MTLD is uncommon in post-primary TB, and diagnosis is difficult due to atypical imaging findings and low organism burden. When traditional methods for diagnosis fail, procedures such as EBUS may increase diagnostic yield. Black mucosal changes can be suggestive of TB. If clinical and radiographic findings are consistent, culture-negative TB may be diagnosed based on response to antimycobacterial therapy. Reference #1: Jeon D. Tuberculous pleurisy: an update. Tuberc Respir Dis (Seoul). 2014;76(4):153-9. Reference #2: Valdés L, Álvarez D, San José E, et al. Tuberculous Pleurisy: A Study of 254 Patients. Arch Intern Med.1998;158(18):2017–2021. https://doi.org/10.1001/archinte.158.18.2017 Reference #3: Kim J, Jang Y, Kim Yo, et. Al. Mediastinal Tuberculous Lymphadenitis Diagnosed by Endosonographic Fine Needle Aspiration. Korean J Gastroenterol. 2016 Dec 25; 68 (6): 312-316. DISCLOSURES: No relevant relationships by richard blinkhorn, source=Web Response No relevant relationships by Hau Chieng, source=Web Response No relevant relationships by Shannon Murawski, source=Web Response

Human babesiosis in Alsace

ObjectivesHuman babesiosis is a rare parasitic anthropozoonosis transmitted to humans by tick bites. Fifty-six cases of human babesiosis have been recorded in Europe. Two cases of babesiosis were reported in Alsace, France, in 2009. We performed a retrospective observational descriptive study to assess the epidemiology of the disease in Alsace. MethodsPatients were included if they had a positive serology result for Babesia and/or a positive blood smear and/or a positive PCR result. The tests were performed in the microbiology laboratories of the university hospitals of Strasbourg, the civil hospitals of Colmar, and the hospital of Mulhouse between January 1, 2005 and December 31, 2015. Included patients were divided into three groups: definite case group (positive PCR or positive blood smear or seroconversion), possible case group (positive serology results without seroconversion with a compatible clinical picture and without other confirmed diagnoses), and incompatible case group (positive serology results without seroconversion, without compatible clinical picture and/or with other confirmed diagnoses). The compatible clinical picture was defined by the presence of flu-like symptoms and fever (≥38°C). ResultsFifty-one patients had at least one positive result. Three cases were excluded (missing files). There were six definite cases, 12 possible cases, and 30 incompatible cases. All patients in the definite case group were immunocompetent. No deaths occurred. ConclusionsHuman babesiosis is probably underdiagnosed due to its non-specific symptoms, lack of awareness about the disease, and the difficulty in making a diagnosis.

068 Serological characterization of anti-p200 pemphigoid: Epitope spreading as a common phenomenon

Anti-p200 pemphigoid is an orphan subepidermal blistering disease characterized by autoantibody binding to the dermal site of human salt-split skin (SSS) and reactivity against a 200 kDa protein in the extract of human dermis by immunoblotting. Here, we aimed at the thorough serological characterization of anti-p200 pemphigoid. This retrospective study included all 243 patients with anti-p200 pemphigoid diagnosed between 2008 and 2017 in our routine autoimmune laboratory. Patients were diagnosed based on a compatible clinical picture and reactivity with the p200 protein in dermal extract by immunoblotting as described previously. In addition, all sera were subjected to indirect immunofluorescence microscopy on SSS and immunoblotting with the extracellular matrix of cultured keratinocytes for reactivity against laminin 332 and ELISA or immunoblotting applying the recombinant NC1 domain of collagen type VII. Autoantibodies against the dermal side of SSS were found in 91% (221/243) of patients and against the p200 protein and laminin γ1 in 100% (243/243) and 88% (209/238) of sera, respectively. IgG reactivity to laminin 332 was observed in 21% (48/233) of patients, in 98% of those (47/48) against the α3 chain of laminin 332. IgG autoantibodies to type VII collagen were detected in 2% (4/243) of patients. 30% (73/243) of sera showed additional reactivity to the epidermal site of SSS. In 58% (42/73) of epidermal binding sera, antibodies against BP180 or BP230 were detected by ELISA, while in 42% (31/73) of these sera, the target antigen remained unclear. In 37% (89/243) of sera, reactivity against one antigen in addition to p200/laminin γ1 and in 7% (16/243) against 2 additional antigens was detected. In summary, in this so far largest cohort of anti-p200 pemphigoid patients, epitope spreading was a common phenomenon and most frequently included laminin 332 followed by BP180, BP230, and type VII collagen.

Is There a Role for Measuring Synovial Biomarkers for Diagnosis of Infected Total Ankle Arthroplasty (TAA)?

Based on the hip and knee arthroplasty literature, measuring synovial biomarkers may play a role in the diagnosis of infected total ankle arthroplasty (TAA). The diagnosis of periprosthetic joint infection (PJI) in the setting of a TAA can be confirmed with cultures, provided that a plausible pathogen is recovered in the context of a compatible clinical picture. In the absence of a positive culture, synovial biomarker analysis may help in establishing the diagnosis. Moderate. Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).

Oseltamivir for the treatment of influenza in children and adolescents

IntroductionInfluenza is a generally a benign disease, but occasionally it can cause serious complications. There is controversy about the benefits of antiviral treatment. ObjectivesTo provide some recommendations on the treatment with oseltamivir in paediatric patients with influenza, based on the best data available and valid in our environment. MethodsThe Respiratory Infections Group of the Spanish Society of Paediatric Infectious Diseases carried out a review of the literature. The findings were analysed using the GRADE methodology, and recommendations were made. ResultsThe systematic use of diagnostic tests for influenza in the outpatient setting, or in the emergency room, in immunocompetent patients with a compatible clinical picture is not recommended. If the aim is to prevent serious events, the use of antivirals is not recommended for the vast majority of healthy and asthmatic patients with influenza or suspected seasonal flu. The systematic use of oseltamivir in patients admitted to hospital with influenza is not recommended. Oseltamivir treatment is recommended in any patients with influenza and pneumonia or severe illness, and critically ill patients, especially during the first 48h of illness. The treatment of patients with risk factors is recommended, considering their underlying disease. Influenza vaccination, together with basic isolation measures, continue to be the main tool in the prevention of influenza. ConclusionIn some situations, there are sufficient data to issue clear recommendations. In other situations, the data are incomplete, and only allows weak recommendations.

Clinical and biochemical differences between hantavirus infection and leptospirosis: a retrospective analysis of a patient series in Belgium

ABSTRACTObjectives: Hantavirus infection and leptospirosis are infectious diseases transmitted by rodents. The clinical picture is nonspecific, often involving the kidneys but other organs can be affected too. Clinical and biochemical clues to make a difference between these two entities will be described.Methods: A retrospective analysis was performed on a database of patients presenting between January 2012 and September 2017 at the emergency department of the university hospital Leuven, Belgium. Patients were selected on the basis of a compatible clinical picture, biochemistry, and microbiological evidence. Presenting complaints and clinical examination were compared. Blood, taken at presentation, was used for hematological and biochemical analysis.Results: Sixteen patients with hantavirus infection and eight patients with leptospirosis were identified. All patients complained about general malaise and fever. Other frequent complaints were myalgia and a headache. Patients with leptospirosis often experienced photo- or sonophobia.Looking for neck stiffness and eye lesions might help to diagnose leptospirosis.Differences in biochemistry between viral and bacterial disease could be recognized; high C-reactive protein (CRP) and leukocytosis with left shift favor leptospirosis, elevated lactate dehydrogenase (LDH) favors viral infection. Abnormal liver function with raised total bilirubin is often seen in cases with leptospirosis.Conclusion: This study demonstrates some subtle clues that may help to differentiate between hantavirus infection and leptospirosis in patients presenting to a hospital in a nonendemic region of the world. Because of small number of patients, we could not identify significant clinical or biochemical tests. Serology remains the gold standard.

Experience of sarcoidosis and factors predicting relapse at a tertiary care institute in North India

Background: Sarcoidosis is a multisystem, chronic granulomatous disease of unknown etiology. The clinical course of sarcoidosis is punctuated with remission and relapses, which is unpredictable. Materials and Methods: This was a retrospective observational study in which case records of all patients with a confirmed diagnosis of sarcoidosis attending the outpatient department of pulmonary medicine department between January 2014 and December 2018 were evaluated. The diagnosis of sarcoidosis was confirmed by demonstration of noncaseating granuloma in cytopathology or histopathology along with a compatible clinical picture. Mantoux test, serum angiotensin-converting enzyme (ACE) levels, serum calcium, and 24-h urinary calcium were done. Results: Sarcoidosis was found to be more common in females. Cough, breathlessness, fever, and fatigue were the predominant symptoms. Mantoux was negative in 95.83%, raised serum ACE was seen in 65.83%, hypercalcemia in 10.83%, and hypercalciuria in 30.0% of patients, respectively. Chest radiograph revealed that 14.17% of patients presented with Stage 1, 52.50% of patients with Stage 2, 15.83% of patients with Stage 3, and 17.50% of patients with Stage 4. Mediastinal lymphadenopathy was seen in contrast-enhanced computed tomography chest in 93.33%, septal thickening with nodularity in 61.67% and fibrosis in 25.83%. Corticosteroids were started in 97.5% patients and 24.17% patients relapsed after stopping or tapering corticosteroids. Conclusion: Sarcoidosis is a common cause of bilateral hilar lymphadenopathy and interstitial lung diseases. Relapses are frequent after stopping corticosteroids, so patients should be followed up actively after stopping treatment.

2033. Incorporating T2Candida Testing into Rational Antifungal (AF) Management: A Successful Pilot Study of Diagnostic Stewardship (DS) Directed Toward Specific Intensive Care Unit (ICU) Patients At-Risk for Sepsis due to Invasive Candidiasis (IC)

BackgroundBlood cultures (BC) are ~50% sensitive for diagnosing IC. T2Candida (T2) detects five leading Candida spp. directly in blood and was ≥90%/90% sensitive/specific (S/Sp) for candidemia in clinical trials. Optimal use of T2 in clinical practice is unclear. We targeted T2 to specific ICU patients at-risk for IC, and implemented AF management algorithms developed with ICU teams.MethodsA DS team ordered concurrent T2 and BC, and used results to guide AF in patients fulfilling pre-specified criteria for septic shock (medical ICU (MICU)), sepsis after abdominal surgery (trauma ICU), or sepsis with mechanical circulatory support (cardiothoracic ICU). We focused on groups with anticipated pre-test IC probabilities of ~3–15%. Proven IC was defined if BC+ and possible IC if BC- but a compatible clinical picture was observed.ResultsSeven percent (6/88) of BC in ICU patients with sepsis were Candida +. T2 and BC results are shown in the table. Using BC as gold standard, T2 S/Sp and PPV/NPV were 50%/87% and 33%/96%, respectively. Including possible IC, T2 S/Sp increased to 69%/96%, and 67% (4/6) of T2+/BC− results were likely true positive; two false-positive results were for C. parapsilosis. We focused on MICU outcomes initially since 75% (66/88) of tests were performed here. Empiric AFs were discontinued in 12 patients following a T2- result; AFs were avoided in all others. Median combined days of therapy (DOT)/month for caspofungin and fluconazole as empiric or definitive treatment prior to and after introducing DS were 26 (range: 10–53) and 15 (3–32), respectively (P = 0.0047). AF consumption was decreased 47% (figure).ConclusionTargeted DS using T2 in select ICU patients with sepsis significantly reduced AF usage. 14% of patients with sepsis were diagnosed with IC using either T2+ or BC+, compared with 7% with BC+ alone, as would be expected if BC S was 50%. T2 S and T2−/BC+ results were lower and higher, respectively, than previously reported, indicating that treatment decisions should be based on results of both tests. Most T2+/BC− results were ascribed to possible IC.Table.Rates of T2 and BC Positive Results and Corresponding Candida Species% (n) tests Candida spp.T2+10% (9)5 CP, 4 CA/CTBC+7% (6)5 CA, 1 CPT2+/BC+3% (3)2 CA, 1 CPT2+/BC-7% (6)2 CA/CT, 4 CPT2-/BC+3% (3)3 CAT2-/BC-86% (76) Disclosures M. H. Nguyen, Merck: Grant Investigator, Research grant. Astellas: Grant Investigator, Research grant.

BIOPSY-PROVEN CENTRAL NERVOUS SYSTEM AND PULMONARY SARCOIDOSIS: FIRST REPORTED CASE IN HONG KONG

SESSION TITLE: Pulmonary SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Lung is the commonest organ to be involved by sarcoidosis. Nervous system is involved in around 5% of cases only. [1] Due to rarity, neurosarcoidosis has never been reported in Hong Kong Chinese patients. CASE PRESENTATION: A 34-year-old Chinese clerk lady presented with headache and personality changes. CT brain showed hydrocephalus and MRI showed ill-defined T2 hyper-intense lesion without enhancement at superior-dorsal aspect of pons. (Fig.1) Endoscopic third ventriculostomy with brain biopsy found granulomatous inflammation with negative mycobacterial tuberculosis polymerase chain reaction (MTB-PCR). CT thorax showed numerous tiny pulmonary nodules with extensive mediastinal lymphadenopathy. (Figs 2,3)She was managed as miliary tuberculosis (TB) with central nervous system (CNS) involvement. Cognitive symptoms persisted despite 8 months of TB treatment and interstitial involvement worsened on CT thorax. Further investigations with transbronchial biopsy and endobronchial ultrasound guided needle aspiration of station 7 lymph node confirmed granulomatous inflammation with negative MTB-PCR. After multi-disciplinary team discussion, diagnosis was revised to be sarcoidosis. TB medications were stopped and she was started on oral prednisolone. The cognitive problem improved and repeat CT 3 months after steroid treatment showed reduced extent of bilateral lung nodules and lymphadenopathy. DISCUSSION: Sarcoidosis was thought to be rare among Asians. The incidence rate ranged from 0.027 (Taiwan) to 2 (Japan) per 100000. Reports in Chinese patients were scarce. The epidemiology in Hong Kong is unknown but there were a number of case reports over last 30 years showing it is not that rare.Diagnosis remained by exclusion from compatible clinical and radiological picture with histology of noncaseating granuloma. [2] This highlighted the diagnostic challenge: TB notification rate was 58.27 per 100000 in Hong Kong; that is 50-2000 times more common than sarcoidosis. Two diseases can overlap, making it more complicated. [3] Many cases therefore received TB treatment during pursuit of diagnosis. Symptoms and signs are non-specific. Usually patients need to have symptoms for more than 3 months, and require three or more encounters with health care providers before arriving diagnosis.Nervous system sarcoidosis is even rarer but it can be first symptoms before systemic disease. Imaging findings are also non-specific. It is difficult to obtain biopsy and some can only be found in autopsy. It is one of the most fearful complications of sarcoidosis as it can carry mortality up to 18%. More aggressive immunomodulating treatment are needed. CONCLUSIONS: Sarcoidosis is still rare but is likely under-recognized. Diagnosis can be challenging in particular to exclude TB. We presented the first biopsy-proven case of central nervous system sarcoidosis in Hong Kong Chinese patient with successful treatment. Reference #1: 1. Dominique V, Antje P, Hilario N, et al. Sarcoidosis. Lancet 2014; 383: 1155–67 Reference #2: 2. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med 1999; 160: 736–55. Reference #3: 3. Wong CF et al. A case of concomitant tuberculosis and sarcoidosis with mycobacterial DNA present in the sarcoid lesion. Chest 1998; 114:2; 626-9 DISCLOSURES: No relevant relationships by Yu Hong Chan, source=Web Response no disclosure on file for Yiu Cheong Yeung